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Global Health: Components of Ethical Work
Global Health: Components of Ethical Work
Global Health: Components of Ethical Work
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Welcome to our live webcast, Global Health, Components of Ethical Work. Thank you for joining us. My name is Mike. I'll be the operator for the presentation today. We are joined today by our moderator, Leslie Rickey, and our speaker, Dr. Joan Blomquist. So this time I'd like to turn the microphone over to Leslie Rickey for opening remarks. Thank you so much. I would like to welcome all of you to our next installment of our AUG virtual forum web-based lecture series. This is a series of presentations by experts in our subspecialty from across the country, focused on topics based on the FDMRS learning objectives, as well as relevant practice-related topics and other topics that are of interest to our membership. The virtual format also provides AUG members the opportunity to interact with the speakers in real time. This presentation will then be captured and made available for view at any time on the AUG website. Upon completion of this program, you will be given the opportunity to provide some feedback, which we greatly value. This evening's presentation, it is my pleasure to introduce Joan Blomquist, who is head of the Division of Urogynecology at Greater Baltimore Medical Center and assistant professor at Johns Hopkins in the Department of Obstetrics and Gynecology. Her presentation today will be Global Health, Components of Ethical Work. Thank you so much, Dr. Blomquist, for being with us today. Sure. Thank you. And thank you all very much for joining. And I'd also like to thank AUGs for taking an interest in global health and having a webinar on this important topic. And actually, this is a perfect day to do this because it's International Women's Day today, which I didn't know until earlier today. With the increase in globalization, along with other factors, there has been an increase in medical missions over the past two decades. There are currently more than 200,000 American global health volunteers who participate in medical missions every year. And they spend $250 million a year. Medical student participation is higher than it's ever been. In 1984, only about 6% of medical students participated in international electives, whereas in 2003, about 30% of students participated. And 28% of OB-GYN residency programs offer global health electives now as well. And as many of us involved in fellowship programs are aware, having a global health elective is important to many prospective fellows and frequently influences their choice of fellowship. Certainly, there are many reasons that medical providers are involved in missions, most of which we believe are altruistic in nature. However, despite its good intentions, global health work does have ethical challenges. And some do question the motives of some volunteers and whether any good is really being done. Short-term medical missions in particular can sometimes be seen as self-serving, raising unmet expectations, being ineffective, imposing burdens on local health facilities, and potentially even being inappropriate if they don't follow current standards of quality care. This past fall, the Global Health Special Interest Group at OGS had a workshop at PFD Week 2016. And the purpose was to address some of these concerns. The workshop included Grace Chen, Louis Wall, Bafid and Mama, Abner Korn, Jessica McKinney, and myself. And I'm hoping over the next 45 minutes or so to highlight some of the topics that we discussed at that workshop. So our objectives for tonight are to review some basic ethical considerations in global health work, discuss different platforms for providing global health care, review pillars of an effective global health program, and then finally to review the importance of volunteer preparation. And I think whether you're considering participating in a program for the first time or whether you've been involved for many years, that you'll find that these are good things to review. Despite the fact that I've worked in global health for more than 12 years now, I find reviewing these concepts are important and they help me to sort of think about the program that I've been involved with as to what we do well, what we can do better, and what's best for the future. So just so you know my background in international work and global health in particular, when I was partway through medical school I took a two-year leave of absence and joined the Peace Corps. And although that was not a specific global health group, I did work on AIDS education while I was there. And then during my fourth year of medical school I spent three months in South Africa on an exchange program. So I have experience as a trainee. And then for the last 11 years or so I've been involved with a small NGO called the International Organization for Women in Development, or IOWD. And this is a nonprofit organization that primarily does work on obstetric fistulas, and I've spent time with that group in Niger, Vietnam, and Rwanda. And although I don't have any disclosures, I am chair of the OGS Global Health SIG, so I might put a few plugs in to join that. So I thought we would use the example of the obstetrical fistula patient tonight as we discuss the various aspects of global health work. So let's start by reviewing some basic information about obstetric fistula to make sure that we're all on the same page. So I'm sure most of you are aware that an obstetrical fistula is a hole that develops between the genital urinary tract and the vagina, or between the gastrointestinal tract and the vagina, as a result of obstructed labor. As a result, after delivery of the child, the woman has sort of constant leakage of urine and or feces, which is obviously extremely distressing. Richard Hamlin and his wife Catherine were a couple from Australia who went to Addis Ababa in the early 1960s to begin a midwifery school. They saw numerous fistula patients when they were there, and they ended up actually opening a fistula hospital and staying in Addis Ababa throughout their entire careers. And I think Dr. Hamlin here very eloquently explains the life of a fistula patient. Mourning the stillbirth of their only child, incontinent of urine, ashamed of their offensiveness, often spurned by their husbands, homeless, unemployed, except in the fields, they endure, they exist, without friends and without hope. They bear their sorrows in silent shame. Their miseries, untreated, are utter, lonely, and lifelong. The causes of vesicle vaginal fistulas in the United States during the 20th century has gone through a major change. As you can see, in the early part of the century, a lot of fistulas were related to obstetrical causes, whereas later in the century, the majority of fistulas were related to GYN surgery. This trend has continued so that we now very rarely see obstetric fistulas in the United States. This is not the case in other parts of the world. In general, maternal morbidity from obstructed labor, such as the development of fistulas, mirrors maternal mortality rates. This map is the World Health Organization map of maternal mortality. As you can see, I'll get my little pointer here, the maternal mortality rates are highest in sub-Sahara Africa and parts of Asia. If you compare the U.S., the maternal mortality rate in the U.S. is approximately 8 per 100,000, whereas in parts of Africa, it's 640 per 100,000 live births. For every maternal death, there are 20 complications that affect maternal health, such as the development of a fistula. This is a map of world birth rates. As you can see, those same places that have the highest maternal mortality rates also have the highest world birth rates. So again, in sub-Sahara Africa and parts of Asia is where they're the highest world birth rates. If we look at Niger in particular, they have one of the highest birth rates in the world with 7.2 births per woman. And if you then multiply that by the high maternal mortality rate, the risk of dying in childbirth in Niger is one out of nine. This is then the World Health Organization map of obstetric fistula. And as you can see, fistula develop in the same places where there's the highest maternal mortality and high fertility rates. So why do these fistula develop? Well, we know that the low socioeconomic status of women can lead to malnutrition, limited social roles, and illiteracy, and this in turn contributes to early marriage and early childbearing. If early childbearing then occurs before the pelvis is completely developed, this increases the chance of cephalopelvic disproportion. If CPD then occurs in a setting where there are not adequate emergency obstetric services, this can result in obstructed labor. And then if the obstructed labor lasts long enough, it can result in what's referred to as the obstructed labor injury complex. So a fistula develops in this situation because the tissue between the fetal bones and the maternal bones gets compressed so that it essentially becomes devascularized. So if that compression occurs between the fetal head and the symphysis, it compresses tissue between the bladder and the vagina. And if that compression occurs between the fetal head and the sacrum, then it compresses the tissue between the vagina and the rectum. Fistulas then develop in different places depending on exactly where that compression was. And there can be fistulas between the bladder and the uterus, the bladder and the cervix, the bladder and the vagina, the UVJ and the vagina, and the urethra and the vagina. Severe tissue trauma, you know, results in this fistula formation, but can also result in other complex urologic injuries, such as renal failure from obstructed ureters and chronic infection. There can be severe vaginal scarring and stenosis, secondary infertility, musculoskeletal injury, foot drop, chronic skin irritation, and obviously an offensive odor. And the majority of the time, the baby dies during this process. It's currently estimated that there are more than 2 million women with untreated obstetrical fistula in Sub-Saharan Africa and Asia, and an additional 50,000 to 100,000 develop each year. Now, in many of these affected countries, the capacity to repair fistula lags behind the incidence. So obviously there's a need for efforts to help with fistula prevention, as well as skilled surgeons to repair the fistula. So what is the best model for providing these services, and what are some ethical considerations when we think about taking care of these women? So I'm sure many of you know Dr. Louis Wall. He is a clinically retired urogynecologist who is still an anthropology professor at Washington University, and he's dedicated a large portion of his career to global health work and has written a lot about the ethics of global health, and has specifically focused on care of women with obstetrical fistula. So let's review a little of his work. And some of these slides that I'm going to show you, he gave me permission to use from our workshop. So hopefully we are all aware of the basic principles of medical ethics. Non-maleficence, which is to avoid harm. Beneficence, to do good. Autonomy, respecting patients. Justice, treat people fairly. And always put the best interests of the patients ahead of other concerns. If you think about it, if we follow these basic principles, we're adhering to the golden rule that applies across all cultures, which is to treat others as you would want to be treated yourself. Now when we apply these principles to global health work, we also need to consider the vulnerable nature of our patients. According to the Council for Organizations of Medical Sciences, vulnerable patients are individuals who are relatively incapable of protecting their own interests. So they are in some way already injured, and then those injuries make them defenseless and predisposed to further injury. Cattell goes on to describe that vulnerable patient groups exist in a determined state of destitution, and that they can only be reduced or neutralized by measures that are specifically designed against the destitution in question and actively applied. So these concerns were really first raised in the context of human subjects research, but if you think about how we provide medical services in the global health setting, we're providing medical services which are not normally available in that country by outside volunteers. So in a sense, this is an experiment in healthcare delivery and thus deserves critical evaluation. So patients that we care for through global health work really need special programs to ensure that all aspects of their care are appropriate. If we think about our typical obstetrical fistula patient, they have certainly already been injured, then they're outcast by society, and they are destitute for help. So they certainly fit the context of a vulnerable patient group and deserve special protection. As Dr. Wall writes, obstetric fistula occur in the so-called bottom billion, which is the poorest 15% of the world population. When they develop a fistula, they're further marginalized and become the bottom of the bottom billion. And unfortunately, the healthcare system in places where the fistulas occurs are frequently overwhelmed by emergencies, and therefore fistula treatment is either not available or is economically out of reach for these patients. As the awareness of the need for care of fistula patients increased in the early 2000s, a number of different organizations started developing programs to help with the care of these women. As this occurred, there was an increasing need to develop some common ethical perspectives, and this then prompted a meeting that was... It was an international meeting that occurred in March of 2007 that was sponsored by ACOG and by the Duke Global Health Initiative. And one of the outcomes of this meeting was the development of the Fistula Surgeons' Code of Ethics. So we're going to summarize some of the primary principles here, but I would suggest that anyone who's planning a global health work should really read the document in its entirety. And this can also certainly apply to care of other vulnerable patient populations. So the first rule is that the fistula surgeon shall be dedicated to providing the best possible care for women with fistulas, permitted by the resources available and the local circumstances. And this is the concept of beneficence. Secondly, the surgeon must treat all fistula patients with respect, dignity, compassion, and honesty. Third, the surgeon's highest duty is acceptance of direct personal responsibility for care of patients on whom he or she operates. And this is the idea that we shouldn't just be coming to do an operation, but we should be acting like surgeons, which means taking preoperative and postoperative care of the patient. The fistula surgeon must restrict his or her practice to that which he or she is competent to deliver by education, training, experience, and available resources. And this is the concept of non-maleficence. Many fistulas are very complex and not something that we take care of on a regular basis in the U.S. Therefore, training as an OB-GYN or urologist or even FPMRS does not automatically make a surgeon competent to take care of fistula patients. The fistula surgeon must practice a method of healing founded on science and should strive to improve his or her clinical skills through regular review of objective data on treatment outcomes. In other words, practice evidence-based medicine. And this also implies that we should be critiquing our own work and then sharing our outcomes with the scientific community so that we can learn from each other. The fistula surgeon must never take advantage of other surgeons The fistula surgeon must never take advantage of a patient nor allow anyone else to take advantage of a patient in a way that might subject her to physical, emotional, economic, or sexual abuse. Fistula surgeons must never pay nor receive a commission for a referral of patients. Fistula surgeons must uphold the dignity and honor of their profession. And finally, fistula surgeons must acknowledge the fundamental social inequalities that promote the development of obstetric fistulas and must help eradicate these injustices. So our social responsibility should extend to the prevention of fistulas as well as prevention of recurrent fistulas. Now it might seem obvious that we should follow these principles but in some global health settings it's not quite as easy as it sounds. We all have to be very careful to make sure that we're providing the same quality of care that we would at home and not think, if it wasn't for me, these people wouldn't have any medical care so what I'm doing is okay. It's better than nothing and it's better than what they have now. But as Dr. Morgan mentioned in a commentary to some of Dr. Wall's writings in 2007, the dictum, first do no harm, must not evolve into first do nothing. So how can we have a program to help these women while being sure that we follow all these ethical guidelines? What's the best way to care for women such as the fistula patients? Well let's take a look at some different platforms of care for surgical missions. This is a study which was designed to propose a classification scheme for platforms of surgical delivery in low and middle income countries and then to review the literature documenting their effectiveness, cost effectiveness, sustainability, and role in training. They reviewed 104 studies between 1960 and 2013. Now previous studies have looked at outcomes such as these but based on the type of surgery performed. So for example, on cleft lip and palate or orthopedic surgery. But this was the first study to look at these outcomes from the perspective of the type of setting in which the care was provided. So as you can see, there are three basic platforms for care. Here the first platform is the temporary short term and this is by far the most common. It's when a team of surgeons, anesthesia providers, and other staff come to low and middle income countries for short periods. Examples of this would be Operation Smile and IOWD which is the group that I'm involved with for fistula care. The second platform is temporary self-contained and this is similar in that a team of surgeons, anesthesia, and other staff come to these countries but they carry their infrastructure with them. So an example of this would be Mercy Ships. And then the third platform is Surgical Specialty Hospital and this is when an NGO establishes an entire physical plant that's dedicated to treatment of one or more surgical conditions. An example of this would be the Addis Ababa Fistula Hospital. So then the second part of this study was to compare these with regards to effectiveness, cost effectiveness, sustainability, and training. And as you can see, the Surgical Specialty Hospital certainly is the gold standard with regards to having effectiveness that's really equivalent to developed world outcomes. It's extremely cost effective. It certainly is sustainable and it's a great place to train surgeons from the low and middle income countries. With regards to the temporary self-contained platforms, there's really very limited research on this so it's really hard to compare but theoretically they really should potentially be equivalent to developed world outcomes. And then if we look at the short-term medical missions, there are some mixed feelings about this. As far as effectiveness, it has been shown to be effective for simple procedures but there are some reports of poor results for more complex procedures. Some reports do show that it can be very cost effective but critics argue that it's not being compared to what may actually be available. And in these cost effective models, they are comparing the cost effectiveness to short-term missions assuming that it's the only platform for surgery that's available. And then in some situations, these programs can be sustainable and they can be effective at training local surgeons. However, that really depends on the individual program. So with regards to the obstetrical fistula, certainly the Hamla Fistula Hospital in Addis Ababa is an outstanding example of a really great way to provide care to these women. The Worldwide Fistula Fund has set up similar hospitals in Niger, Ethiopia, and Uganda. And these are really great programs that provide comprehensive services to women suffering from obstetric fistula. They include surgery and then they also include social services, physical therapy, and vocational training, which is important for empowerment and reintegration of these women back into society. And although these are outstanding examples of how to care for the fistula patients, there currently are not enough of these type of programs to help everyone. So short-term medical missions are still needed to fill the gap. So how can we make short-term medical missions effective? Well, there are a number of publications with suggestions or guidelines for short-term medical missions, and I thought I'd review three such set of guidelines that come from three different sources. So Judith Lasker is a sociology professor at Lehigh University, and her recent book, which was published in 2016, is a culmination of more than 100 surveys and interviews that she did with various sponsoring organizations, volunteers, and host communities. And she looked at questions such as, do volunteers help? Can they do harm? Is the amount of money spent justified? What is the evidence? She then looks at the principles for maximizing the benefits of volunteer health trips and describes what she calls the pillars of an effective program. And based on her work, she proposes that mutuality or partnership and continuity are the two most important principles of an effective program. She also talks about the importance of performing a needs assessment to evaluate process and outcomes and incorporate the results into improvements, in other words, do quality improvement projects, focus on prevention, integrate diverse types of health system services, build local capacity, strengthen volunteer preparation, and have volunteers stay longer. This next set of guidelines is proposed by a group out of University of Washington who travels to El Salvador to do public health work. The group is called CHIMPS, which is the Children's Health International Medical Project of Seattle. It was started in 2002 and sends faculty and residents at the University of Washington to El Salvador. They've been working to support ongoing public health interventions there and to provide sustainable medical care in collaboration with the community and local NGOs. So the principles that they feel have allowed them to become successful are, number one, to have a mission statement, and by this they mean to have a common and specific sense of purpose that's shared between the University of Washington and El Salvador participants. Collaboration, a relationship with the community and its infrastructure. Education, and by this they mean education of themselves, the community, and their peers. By service, they mean a commitment to doing work that the community needs and wants. Teamwork, building on each team member's skills and experiences. Sustainability, and then having a process of evaluation. In other words, a mechanism to determine whether their goals are being reached. And then the final example of guidelines is based on work by Grimes et al., in which they reviewed the available literature and then consulted experts to establish consensus guidelines for any surgeon concerning participation in surgical missions. And the things that they found important were, number one, to understand local needs and resources, and this means understanding local priorities and using local resources whenever possible to allow for sustainability. Secondly, to train local health providers, and this doesn't just mean surgeons, but also anesthesia providers and nurses, and they emphasize that sending multidisciplinary teams is extremely helpful. Use of appropriate technologies and skills. As we saw, short-term medical missions do better with simple procedures, and therefore we need to be very cautious about complex procedures, and this is true for equipment as well. For example, a program introducing the use of ultrasound for detection of intra-abdominal bleeding in trauma patients in Uganda was not able to be maintained over the years because they were having problems with maintenance of the ultrasound machine, its safety, and its availability. The World Health Organization has produced guidelines for donation of medical equipment, which is helpful guidelines to look at. They also recommend monitoring the quality of the surgery, and this is particularly true for short-term medical missions, as there's questions as to whether the outcomes are as good as expected in different settings. Manage post-op complications. This is obviously important that the local staff is trained, especially if the group is planning on leaving before full recovery of the patients. And this, you know, particularly to fistula patients goes back to one of the things we talked about in the Code of Ethics by Dr. Wall. With regards to cost, in addition to considering the cost of the volunteer, we need to consider the cost incurred by the host hospital, such as use of extra supplies, electricity, equipment, personnel, and also thinking about that the ORs are not being used for what they would normally be used for during the regular schedule, so they're losing income that way. In addition, there's costs of just having extra patients around, like who's going to pay for the transportation for them to get there, who's going to pay for their food, and so forth. And then sustainability and working with local and regional training programs. So as you can see, there's a lot of similarity with regards to these guidelines, whether they're developed by sociologists, like health workers or surgeons. So let's talk in a little more detail about some of these guidelines and talk through some examples. Partnering with a local hospital or clinic we've seen is obviously very important, and returning to the same location year after year is vital. And I really think that's the only way to develop the mutuality and continuity that Judith Lasker talked about. So as an example, the group that I work with, IOWD, has partnered with Kabagabaga District Hospital in Rwanda, and we go back to the same hospital three times a year. And we've actually just completed our 22nd mission there. So by going back 22 times, we've really developed a strong partnership, and that has a number of advantages that we can really see. It's allowed us to develop relationships, not just with the local doctors, but also with the staff and the administration there. It's allowed us to create sustainability through collaborative relationships, and an example of this is that we can now see evidence that when we're not there, they are still doing the surgical timeouts, they're still doing the instrument counts, they're still doing some infection prevention things that we worked with them to develop. The other thing is that there's a much better way to look at outcomes. You know, if you don't go back to the same place all the time, you really don't have a way of knowing, are you having any postoperative complications? Are you having any failures? But by having a good partnership where you've got local physicians to help you to follow up the patients, you can really assess your outcomes and come up with better ways of doing things. It also allows for preparation to be ongoing all year so that you're not reinventing the wheel each time that you come. And one of the other things that we've really learned has helped is that if the same volunteers return year after year, then that allows that partnership to be even stronger. Now we mentioned in all three of the guidelines that we looked at the importance of doing a needs assessment, and obviously understanding the medical issues facing the country is an important first step when you're first setting up a program, but this also needs to be an ongoing process. The group needs to work with the Ministry of Health and local hospitals and providers to determine their priorities. And services offered should not be based on what physicians want to come, but providers should be recruited based on what the country needs. So just because you have a plastic surgeon who wants to come with you, if the country doesn't need one, then that's not really a priority. And obviously an understanding of the community's cultures, traditions, and perception of health and disease are also really important. So as I mentioned in the beginning, I've done work in both Niger and Rwanda with IOWD, and I think you'll see as I review some of the differences between these two countries how important a needs assessment can be. So Niger is a desert located in Western Africa, whereas Rwanda is in Eastern Africa and is a rainforest. Niger is about three times the size of California and has a population of 17.2 million, whereas Rwanda is about the size of Maryland and has a population of 11.5 million. Thus Rwanda is a much more densely populated country. In Niger, school attendance is about 34% and literacy is 15%. In Rwanda, school attendance is 75% and literacy is 70%. If we look at differences in the health system, you can see that Rwanda spends much more money on healthcare than Niger does, 10.8% of GDP compared to 5.3%. In Rwanda, most women are covered by a community-based health insurance scheme, whereas in Niger only 10% of people have any kind of insurance coverage. And the infant mortality rate is significantly higher in Niger. We saw early on that the role of women is important with regards to development of fistula, and if you look at various aspects of the role of women, you can see big differences between Niger and Rwanda. The gender inequality index is higher in Niger, the adolescent fertility rate is higher, and the maternal mortality rate is higher. Another marker of role of women is to look at the ratio of women to men in Parliament, and you can see it's very low in Niger, whereas there's actually more women in Parliament than men in Rwanda. The differences between the two countries means that the medical needs are different. So this is some unpublished data about our fistula patients for some of our work in Niger and the first three years that we were in Rwanda. And what I'd like you to notice is let me get my little pointer down here. The age at presentation is different in Rwanda because of the better role of women. They have delayed childbearing, and so they present later. The other thing I want you to notice is the difference between whether the fistulas occur after vaginal delivery or a C-section. In Niger, almost all of the fistulas that we saw were after a vaginal delivery, whereas in Rwanda you can see that there's a higher percentage that occur after C-section. And this trend has continued so that we now are actually seeing more fistulas after C-section than after vaginal deliveries. And this is related to the healthcare system that exists in Rwanda. Because it's a more densely populated country and has a better healthcare system, there's easier access to care. However, once the women get to care at these healthcare facilities, the care there still needs improvement and there are complications with the C-sections. This obviously has a bearing on the type of fistulas that we're seeing, and fistulas that occur after a C-section are more likely to involve the ureter and the cervix and the uterus. These rectovaginal fistulas that we're seeing down here are really fourth-degree tears that just weren't repaired rather than true fistulas. So these findings have had a big impact on how our group is organized and what we need to do to prepare for the mission. So in Rwanda, we know that we have to be prepared to deal with fistulas that involve the ureter, so we have to make sure that we have people who come along who are comfortable doing ureteral re-implants and who do them regularly at home and are able to teach the local providers. It's also important for our follow-up care because we have a lot of patients who have stents in Rwanda, and so we have to be sure that we have a good relationship with the urologist in town who can help deal with any complications that might arise. And these differences are also very important with regards to how we work on prevention in Rwanda. Rather than focusing on access of care, we've been focusing on C-section techniques, and one of our physicians worked with a group of local physicians to develop a video on proper techniques for C-section, and this is now being used regularly in teaching around Rwanda. So a needs assessment is really important and has a big impact on how you develop your program. So all three sets of guidelines also mention that it's very important to evaluate the quality of our care, and medical missions are certainly not exempted from evaluation due to their altruistic or transient nature, and rather because of the vulnerability and substantial medical needs of the populations they serve, medical mission groups in particular stand to benefit from a means to objectively inform the healthcare decisions they make. So evaluation of our quality care is very important. So then the question comes up, well, what do we measure and how are we actually doing? This is a very interesting study that I think is very helpful that was published in 2008 that looked at health impact assessment and short-term medical missions, and this was a three-phase study. Phase one was a base need analysis, phase two was designing a survey, and then phase three was pilot testing. So in phase one, the group evaluated six missions in Honduras, Guatemala, and Venezuela, and they selected different missions based on their size, the medical goals, and social affiliations so that they had a broad heterogeneity of types of short-term medical missions so that these results would be more generalizable. When they went on each of these missions, they did in-depth interviews with the program directors, the personnel, and the recipients of the care to answer the question, what are the most important factors in evaluating the quality of short-term medical missions? And from these interviews, they determined that there were six major points that were uniformly discussed by all the missions. In phase two, then, they designed a survey that was based on six major as well as 30 minor factors that were found in these surveys. And then in phase three, they pilot tested the survey in five short-term medical missions in Honduras, Ecuador, Brazil, Zimbabwe, and Namibia. So this is the six major factors that were found to be important in short-term medical missions, which are cost, efficiency, impact, preparedness, education, and sustainability. And then this model here is an example of what would be given as a summary to a mission. So this is mission A, and as you can see, they did very well with regards to sustainability, but they probably need to focus a little bit more on education. So this is sort of how the information would be shared with the different missions. And then this is the results of phase three, where they evaluated five different missions. And as you can see, the different missions had different strengths and different weaknesses. If we look overall at the average in the last column, most missions did well with regards to cost and impact, but they probably need to improve on education. So this, I think, is a really efficient and user-friendly tool that's a way of self-evaluation that focuses on quality and health impact. It's referred to as being available online at stmmconnect.org. However, unfortunately, this website is no longer available, and so we might have to reinvent the wheel in order to start something like this up again. But I think it's a great example of the type of tool that we really should be using to evaluate our mission work. So finally, as mentioned at the various guidelines, volunteers must be prepared before participating in medical missions. And the following slides that I'm going to share with you on pre-departure preparation are shared by Grace Chen for her part of our workshop that we did in Colorado. As part of an ACOG effort to learn more about global health preparation, Lee Lehrman conducted a number of interviews with OBGYN departments who have global health electives and summarized their recommendations. And basically, pre-departure preparation consists of four areas, including knowledge, logistics, which includes personal health and safety, ethics and culture, and adaptability. Most existing OBGYN departments have these programs that are geared towards trainees, but they can also be used for faculty as well. And most departments use a combination of pre-departure handbooks, online resources, in-person sessions, including didactic sessions, various discussions and simulations, as well as Skype sessions with international colleagues. So let's go through these four different areas and I want to give you some important resources to help with all of pre-departure planning for all of these. So most of the time, knowledge can be gained by doing online modules and there are some great online modules at these various sites here that have good information on basic knowledge for medical missions. Unite for Sight is a really good, they've got all sorts of modules and you can actually get a little certificate by going through a lot of them. USAID has some, JPIGO, APCO, UCSF, and the Hopkins Consortium of Universities. This is an example from the APCO website, which has some excellent videos on general knowledge about global health and then also has videos on specific topics such as maternity care and fistula. Logistics can generally be learned from pre-departure handbooks and Hopkins has actually a really good pre-departure handbook that's a general framework for health trainees and it draws upon current global health education literature and existing handbooks from other institutions and it was developed by medical students, residents, fellows, and academic physicians, but it was also vetted by global health coordinators and U.S. and international members of AUGS and IUGA. And this is available on the AUGS website in the global health special interest group. So if you go, if you join the global health special interest group and go to that part of the website, the handbook is right there. And it has all sorts of great information, just general topics on advice on how to gather country specific information, what countries need a visa, how to think about doing your medical license and permission in these countries, has information on personal health and safety such as vaccinations and whether to think about medical and evacuation insurance. It talks about cross-cultural preparation and it also has information about people who might be doing research when they're overseas on how to do design and do IRBs. And it even has things like a packing list and then some good resources for online preparation. For ethics and cultural preparation, there are a number of online resources available through the Hopkins Berman Institute of Bioethics and Stanford Center for Innovation in Global Health, also from Unite for Sight and University of Toronto. And these are things that can be done either individually or they can be done in small groups if you have a group of students or residents or fellows who are going, then they can work on these together. And then there's a very interesting resource available for preparing for adaptability. SUGAR stands for Simulation Used for Global Away Rotations and it's a simulation based curriculum that's used to prepare medical providers for common challenges that might be faced when they're working in resource limited settings. And if you go to the website, they can-this can actually be used to train the trainees and there's some great clinical scenarios that are used for the simulation training. This is from the Hopkins Global Health website and lists the requirements for preparing for global health electives that they require their students to do. And as you can see, they're required to review the pre-departure handbook and then complete some online courses. They then have a full in-person pre-departure day, which includes lectures as well as some simulations. And then they're also required to complete the Berman Ethics modules. Equally as important to pre-departure planning is post-departure debriefing. And at Hopkins, they actually have a post-departure debriefing day also where they bring people who've-committee members together and people who have been on various different electives to sort of review what they learned and share some of their research that they did and, you know, relate some personal experiences. And not only is this helpful, I think, for the participants, but also it provides good feedback so that they can modify programs in the future. And I think this is something really important that we tend to forget about doing and just come home and go back to our lives without really thinking about the importance of debriefing. So in summary, global health work can be very rewarding and, if done properly, can be very effective and provide sustainable care. But there-I would kind of caution to not take involvement in global health lightly. It takes a lot of time and commitment and obviously it's important to follow basic ethical principles. It's really important to be well prepared and there are all sorts of resources that are available so that you can be well prepared. And I think with that, if you are someone who goes regularly and brings trainees with you, that it's our obligation to make sure that the people-the trainees that we bring with us are well prepared. It's important to investigate the organization that you might consider going with to make sure that your values match their values. It's important to constantly reassess your efforts to make sure that we really are providing quality care. And then I will put a plug in for joining the AUGS Global Health SIG. It's a great opportunity to network with other people who are interested in global health, to learn what programs are available, and also for us to learn from each other about our successes and our challenges. So thank you very much and I am happy to take any questions that people might have. All right, and at this time, just a reminder, the Q&A is located on the right-hand side of your screen. To submit a question, type your question in the small text box at the bottom. When you're finished, you can click the send button or push enter. Please note, our panel may not respond to all the questions submitted due to time constraints, but I will turn things back over to our presenters and Leslie in particular to see if there are some questions you'd like to begin with. Hey, Joan, that was a really incredible presentation. I really appreciate the attention to some of the details we need to think about beyond just going and operating. So I think that was super helpful. One of the questions that came to my mind is, has there been any change, any trend in the decrease, maybe incidence in some of these obstetric fistulas happening in the third world with this really significant increase in volunteers going over and increase in education? Have you all seen any decrease? Because obviously prevention is, I guess, the goal. But has there been any decrease in the incidence of these issues over the maybe one or two decades that these numbers of volunteers have been increasing? You know, I think that's a really hard thing to look at because these estimates are, you know, really kind of estimates of how many people have fistulas. You know, certainly if you look like the information that I showed you between Niger and Rwanda, there's a change in how the fistulas are occurring. And, you know, even just in our time that we've been in Rwanda, we've seen a change in the fistulas and we're even seeing now that we're seeing more prolapse patients rather than fistula patients. So I think that there really is, but it's a hard thing to measure because a lot of places where these occur, they're not really getting any care. So we don't really know exactly how many women have fistula. You know, another question I had, and I saw your graph on, or your table on the temporary interventions versus the specialty hospitals was interesting. And I was wondering, you've been doing this for such a long time. Do you have any insight on how you would move from a temporary visit to a more of a specialty hospital long-term situation? Well, I think that's really one of the advantages of the short-term medical missions, or not advantages, but one of the sort of long-term goals is that would be the ideal thing to do. And going to the same place again and again, I think, is what allows you to figure out is it really needed in that location and then how to develop that. The Worldwide Fistula has the programs in Niger and Ethiopia and Uganda is really doing that in Uganda right now, where they have some areas where they're having fistula camps, and then the ultimate goal is to create those into hospitals. So I think you really need a big organization like that with a lot of experience to make it work and a lot of good funding. I think it's hard for smaller groups like the one that I'm involved with to really do that. I think probably the answer is really in the bigger organizations like the Worldwide Fistula Fund. All right. I mean, I know it takes a good amount of funding also, and the consistency sounds important also. And I'm sorry, I'm hogging all the questions, but that was so fascinating. I have some more. Okay. So you mentioned, importantly, that I think we really in the United States and developed countries don't have necessarily the skill sets, even in specialty training, to deal with some of these really complex fistulas. We just don't see that in any of them. So outside of the obvious, I mean, what would you recommend for someone that's maybe in practice that would like to do this that says, you know what, I know how to do fistulas. I've seen some sort of complex ones, but ones that are three centimeters big. What's the best route for me to get trained in this so that I am achieving, you know, both the ethical and the patient care goals? Well, it kind of reminds me back when my husband worked for Catholic Relief Services when I first, when we were younger, and I first moved to Baltimore. And one of the things he did as part of working with Catholic Relief is he visited a number of different countries, and he went to Ethiopia and actually went on a tour of the Hamlin Fistula Center there. And he said, oh, my wife would love this. She would love to get involved in this. And, you know, she'd love to come over and train. And they said, whoa, whoa, whoa, we're really not interested in training American physicians. We want to train our local African physicians because they're the ones who are going to stay here and do this for the future. And so that's a really important thing, I think, that, you know, the goal should not be to train us to do this, but to train the local physicians. But having said that, if it's something that someone really wants to dedicate their career to, then working with a group like the Worldwide Fistula Fund and really spending extended time periods with the idea that that's your long-term goal. You know, working with smaller groups like ours, after you go so many times, you develop these skills. But there are studies that show that you really have to do like 300 fistula operations before you really are competent. And so I think for doing simple fistulas, you know, working with groups like ours is good. But, for example, we do not do urinary diversions in our group because we just don't have the setup to be able to follow these patients and make sure that we have everything in line. And I think those things really should still be done in the specialty hospital. Thank you. And I think, you know, absolutely, I, you know, I agree it should not be viewed as a training ground for people that have that skill. You know, but at the same time, I think what you alluded to, there are lots of people with very, you know, developed vaginal surgery skill sets that could benefit, hopefully educating, because I know the main goal is educating the local providers so that when you're gone, you know, they can continue on with the care and the surgery. So anyway, it's a tough, it's a tough question, you know, and I think some of the questions you posed were, you know, do you want to go and do good for a day or do you want to do good for a decade? And I think everybody would agree we want to do, you know, the right thing for the decade in the future is just sort of how to achieve that. And I think you touched on the need for research. And I have a friend that works in IVU and she has said the same thing, that the research is hard, the quality metrics are hard to measure, but they're really, really important in these situations. Yeah, absolutely. To know if what we're doing is really making a difference. Yeah. Yeah. So I just want to wrap it up and say thank you to Dr. Blomquist for that fantastic presentation. I really appreciate it. And I think all of this is, you know, I wanted to disseminate this further the best we can. So, you know, we, as always, learn so much from a great educator. And I want to thank you for everybody on the call, as well as Dr. Blomquist for carving time out of your busy day to participate in this virtual forum. And again, provide any feedback after completion of the program. We really do take that into account when planning future programs. So again, thank you to everybody and thank you for carving night out of your evening and go back to your non-webinar activities. Thank you. Thank you. Thanks again, Joan.
Video Summary
The video is a recording of a live webcast titled "Global Health: Components of Ethical Work." The webcast is hosted by a moderator named Leslie Rickey and features a speaker, Dr. Joan Blomquist. Dr. Blomquist is the head of the Division of Urogynecology at the Greater Baltimore Medical Center and an assistant professor at Johns Hopkins in the Department of Obstetrics and Gynecology. The presentation discusses the increase in medical missions over the past two decades and the ethical challenges and questions surrounding global health work. Dr. Blomquist highlights the need for programs to ensure that all aspects of care provided are appropriate and adhere to ethical guidelines. She discusses various platforms for providing global health care, including temporary short-term interventions, temporary self-contained interventions, and surgical specialty hospitals. Dr. Blomquist also emphasizes the importance of pre-departure preparation for volunteers and provides resources and guidelines for preparing for global health work. The presentation concludes with a Q&A session. No credits or sources were mentioned.
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Joan Blomquist, MD
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Practice/Professional Concerns
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Global Health
Ethical Work
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Leslie Rickey
Dr. Joan Blomquist
Medical Missions
Ethical Challenges
Global Health Care
Pre-departure Preparation
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